The benefits and problems of targets
20. Studies of the impact of targets usually describe two issues. Firstly, there is little doubt that they produce improvements in the process that has been targeted. Secondly, most studies also identify problems. For example, in a review of two target setting policies, Elkan and Robinson (1998)  examined the effectiveness of targets in the delivery of two UK Government policies: the 1992 Health of the Nation strategy and the 1990 General Practitioners' Contract. They concluded that the introduction of both policies was accompanied by improvements in performance. They also found that targets caused a number of problems. They felt that targets tended to focus action on those things that were most easily measured, that they could foster complacency on the part of providers who have already achieved target levels of performance, and defensiveness on the part of those performing badly. They felt that national targets might adversely affect local priorities. They also suggested that targets might widen inequalities in health by being unrealistic and unattainable in deprived populations. Their paper concluded that a target-setting approach to improving the quality of care must be based on the appropriate use of indicators, and must take account of differences between more and less advantaged sections of society.
21. In 2010, The Kings Fund  , examining the impact of targets in the NHS in England concluded: "enforced targets do appear to have been successful in improving aspects of NHS performance, particularly in relation to waiting times, but there is some evidence of unintended consequences – for example, distortion of priorities or neglect of other non-targeted activities. However, it is important to recognise that such unintended consequences may not be the inevitable result of targets in themselves, but rather of the way in which those targets were designed or implemented.
22. This Kings Fund report refers to targets in the NHS and we are concerned about how to manage a whole system of collaborating agencies which have manifestly different cultures. The danger of targets having unintended consequences is probably magnified when different agencies are jointly responsible for delivering them. This is an issue which requires careful consideration.